Management of acute fractures and nonunions of the proximal pole of the scaphoid.

It is my belief that all acute proximal pole fractures should be treated by open reduction and internal fixation, via a dorsal approach. There is no longer any place for conservative treatment of these fractures, because a lengthy period of plaster immobilization is required and there is an unacceptably high risk of nonunion with conservative management. Unfortunately, nonunion of the proximal pole remains a common and disabling problem which demands careful evaluation and treatment. Internal fixation combined with limited cancellous bone grafting produces very satisfactory results in terms of pain relief and function, and clinical results are as good as those reported for more complex procedures involving vascularized grafts and prolonged cast immobilization. While the place for vascularized grafting has yet to be clearly defined, at present it is a technique which should be reserved for cases with long-standing ischaemia or failed previous surgery.